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Purpose Brachytherapy is an essential technique to deliver radiation therapy and is involved in the treatment of multiple disease sites as monotherapy or as an adjunct to external beam radiation therapy. With a growing focus on the cost and value of cancer treatments as well new payment models, it is essential that standardized quality measures and metrics exist to allow for straightforward assessment of brachytherapy quality and for the development of clinically significant and relevant clinical data elements. We present the American Brachytherapy Society consensus statement on quality measures and metrics for brachytherapy as well as suggested clinical data elements. Methods and Materials Members of the American Brachytherapy Society with expertise in disease site specific brachytherapy created a consensus statement based on a literature review and clinical experience. Results Key quality measures (ex. workup, clinical indications), dosimetric metrics, and clinical data elements for brachytherapy were evaluated for each modality including breast cancer, cervical cancer, endometrial cancer, prostate cancer, keratinocyte carcinoma, soft tissue sarcoma, and uveal melanoma. Conclusions This consensus statement provides standardized quality measures and dosimetric quality metrics as well as clinical data elements for each disease site to allow for standardized assessments of brachytherapy quality. Moving forward, a similar paradigm can be considered for external beam radiation therapy as well, providing comprehensive radiation therapy quality measures, metrics, and clinical data elements that can be incorporated into new payment models.

purpose This practice parameter aims to detail the processes, qualifications of personnel, patient selection, equipment, patient and personnel safety, documentation, and quality control and improvement necessary for an HDR brachytherapy program. Methods and Materials This practice parameter was revised collaboratively by the American College of Radiology (ACR), the American Brachytherapy Society (ABS), and the American Society for Radiation Oncology (ASTRO). Results Brachytherapy is a radiotherapeutic modality in which radionuclide or electronic sources are used to deliver a radiation dose at a distance of up to a few centimeters by surface, intracavitary, intraluminal, or interstitial application. Brachytherapy alone or combined with external beam radiotherapy plays an important role in the management and treatment of patients with cancer. High-dose-rate (HDR) brachytherapy uses radionuclides, such as iridium-192, at dose rates of ≥12 Gy/hr to a designated target point or volume, and it is an important treatment for a variety of malignant and benign conditions. Its use allows for application of high doses of radiation to defined target volumes with relative sparing of adjacent critical structures. Conclusions HDR brachytherapy requires detailed attention to personnel, equipment, patient and personnel safety, and continuing staff education. Coordination between the radiation oncologist and treatment planning staff and effective quality assurance procedures are important components of successful HDR brachytherapy programs.

From both a disease and management perspective, locally advanced gynecologic cancers present a significant challenge. Dose escalation with brachytherapy serves as a key treatment, providing conformal radiation while sparing at-risk organs. Intracavitary brachytherapy techniques have been shown to be effective, with improving tumor control and toxicity profiles with the advent of three-dimensional image planning. Despite this, the variations in tumor size, location, and pelvic anatomy may lead to suboptimal dosimetry with standard intracavitary applicators in some clinical scenarios. The addition of interstitial needles (interstitial brachytherapy (interstitial brachytherapy) can improve the conformality of brachytherapy treatments by adding needles to peripheral (and central) regions of the target volume, improving the ability to escalate doses in these undercovered regions while sparing organs at risk. Interstitial brachytherapy can be delivered by intracavitary and interstitial hybrid applicators (ICBT/ISBT), perineal template (P-ISBT), or by free-hand technique. ISBT has however yet to be widely available because of concerns of complications and toxicities from this specialized treatment. However, with the increasing use of three-dimensional image-guided brachytherapy, there is an opportunity to increase the level of expertise in the gynecologic radiation oncology community with an improved understanding of the potential complications and morbidity. In this article, we review the acute and long-term toxicity in both ICBT/ISBT and P-ISBT using image-guided brachytherapy.

Purpose Brachytherapy (BT) after surgical resection of keloids reduces the risk of local recurrence, but standardization of dose/technique is lacking. Typical keloid BT treatment utilizes a single-channel source prescribed to 5-mm depth. We investigated the dosimetry of a volume-based target definition for interstitial high-dose-rate BT treatment of keloids. Methods and Materials We retrospectively identified consecutive 14 patients who had a total of 20 keloids treated with interstitial high-dose-rate BT for keloids at our institution between 2004 and 2014. Keloids were treated with a single 8 Gy fraction prescribed to 5 mm beneath the scar within 36 h of surgery. Retrospectively, a 3-mm skin high-risk clinical target volume (HR-CTV) was contoured under the scar for volume-based dose calculations. Results Mean (SD) HR-CTV was 3.91 cm3 (3.1) and mean (SD) HR-CTV dose was 11.3 Gy (3.6). Mean D90 (SD) was 62.9% (25.8) and mean V100 (SD) was 56.5% (26.4). The mean V150 (SD), V200 (SD), and V300 (SD) were as follows: 37.6% (19.9), 25.1% (14.4), and 11.3% (6.5), respectively. No local failures were reported at 9 months median followup. There were no Grade 2 or higher late toxicities. Conclusions Using a volume-based target definition, a wide range of target coverage was observed. This is likely a consequence of the curvature of the skin and the challenges of keeping the catheter equidistant from the skin across the target. Additional data are needed to define the potential clinical impact on outcomes/toxicities of dosimetric correlates with single-catheter BT keloid treatment.

Purpose Keratinocyte carcinoma (KC, previously nonmelanoma skin cancer) represents the most common cancer worldwide. While surgical treatment is commonly utilized, various radiation therapy techniques are available including external beam and brachytherapy. As such, the American Brachytherapy Society has created an updated consensus statement regarding the use of brachytherapy in the treatment of KCs. Methods Physicians and physicists with expertise in skin cancer and brachytherapy created a consensus statement for appropriate patient selection, data, dosimetry, and utilization of skin brachytherapy and techniques based on a literature search and clinical experience. Results Guidelines for patient selection, evaluation, and dose/fractionation schedules to optimize outcomes for patients with KC undergoing brachytherapy are presented. Studies of electronic brachytherapy are emerging, although limited long-term data or comparative data are available. Radionuclide-based brachytherapy represents an appropriate option for patients with small KCs with multiple techniques available. Conclusions Skin brachytherapy represents a standard of care option for appropriately selected patients with KC. Radionuclide-based brachytherapy represents a well-established technique; however, the current recommendation is that electronic brachytherapy be used for KC on prospective clinical trial or registry because of a paucity of mature data.

Purpose Brachytherapy is utilized in the treatment of many different malignancies; although traditionally performed with low-dose-rate or high-dose-rate techniques, more recently, electronic brachytherapy (EB) has emerged as a potential alternative. At this time, there are no evidence-based guidelines to assist clinicians in patient selection for EB and concerns exits regarding differences in dosimetry as compared to traditional brachytherapy techniques. As such, the American Brachytherapy Society appointed a group of physicians and physicists to create a consensus statement regarding the use of EB. Methods and Materials Physicians and physicists with expertise in brachytherapy created a site-directed consensus statement for appropriate patient selection and utilization of EB based on a literature search and clinical experience. Results EB has been utilized to deliver accelerated partial breast irradiation with, thus far acceptable local control and toxicity rates including a randomized trial that used EB to deliver intraoperative radiotherapy; however, prospective data with large patient numbers and long-term follow up are needed. Increasing numbers of patients have been treated with EB for nonmelanomatous skin cancers; although, preliminary data are promising, there is a lack of data comparing EB to traditional radiotherapy techniques as well as a lack of long-term follow up. For treatment of the vaginal cuff with EB, small retrospective studies have been reported without long-term follow up. Conclusions In light of a randomized trial in breast showing higher rates of recurrence and the lack of prospective data with mature follow up with other sites, as well as concerns regarding dosimetry, it is not recommended that EB be utilized for accelerated partial breast irradiation, nonmelanomatous skin cancers, or vaginal cuff brachytherapy outside prospective clinical trials at this time.

As brachytherapy utilization rates decline, we sought to evaluate the state of brachytherapy training during radiation oncology residency.US radiation oncology residents in the Association of Residents in Radiation Oncology database were sent an online questionnaire regarding brachytherapy training. Survey questions addressed a wide array of topics, and responses were often given on a 1 to 5 Likert-type scale that reflected strength of opinion. Postgraduate year (PGY) 4/5 respondents' answers were analyzed. Descriptive statistics were generated, and rank correlation analyses (Kendall's τ coefficient and Wilcoxon signed-rank test) were used for comparisons.The survey was completed by 145 of 567 residents (62% being PGY4/5). Of PGY4/5 respondents, 96% (86 of 90) believed learning brachytherapy during residency was important, and 72% (65 of 90) felt their program valued brachytherapy training. Resident brachytherapy comfort varied by site, decreasing as follows: gynecologic, prostate, breast, skin. The current intracavitary 15-case minimum was believed adequate by most, but only a minority believed the 5-case interstitial minimum was adequate. Most respondents (59%) believed that caseload was the greatest barrier to achieving independence in brachytherapy. Significant support exists for American Brachytherapy Society training courses and on-the-job education to enhance training, but enthusiasm about pursuing brachytherapy fellowship training was low. Most respondents expressed confidence in developing a brachytherapy practice (54%); however, this was significantly lower than the rate of those confident in developing a stereotactic body radiation therapy/stereotactic radiosurgery program (97%) (P .001). Furthermore, there was an association between aggregate number of brachytherapy cases performed and resident confidence in starting a brachytherapy practice (τ = 0.37; P .001).Brachytherapy is an important component of residency training that is valued by residents and programs. Because caseload was the greatest perceived barrier in brachytherapy training, with confidence correlated with case volume, attempts should be made to expand opportunities for training experiences that are feasible to complete during residency.

Purpose Daily magnetic resonance (MR)–guided radiation has the potential to improve stereotactic body radiation therapy (SBRT) for tumors of the liver. Magnetic resonance imaging (MRI) introduces unique variables that are untested clinically: electron return effect, MRI geometric distortion, MRI to radiation therapy isocenter uncertainty, multileaf collimator position error, and uncertainties with voxel size and tracking. All could lead to increased toxicity and/or local recurrences with SBRT. In this multi-institutional study, we hypothesized that direct visualization provided by MR guidance could allow the use of small treatment volumes to spare normal tissues while maintaining clinical outcomes despite the aforementioned uncertainties in MR-guided treatment. Methods and materials Patients with primary liver tumors or metastatic lesions treated with MR-guided liver SBRT were reviewed at 3 institutions. Toxicity was assessed using National Cancer Institute Common Terminology Criteria for Adverse Events Version 4. Freedom from local progression (FFLP) and overall survival were analyzed with the Kaplan-Meier method and χ2 test. Results The study population consisted of 26 patients: 6 hepatocellular carcinomas, 2 cholangiocarcinomas, and 18 metastatic liver lesions (44% colorectal metastasis). The median follow-up was 21.2 months. The median dose delivered was 50 Gy at 10 Gy/fraction. No grade 4 or greater gastrointestinal toxicities were observed after treatment. The 1-year and 2-year overall survival in this cohort is 69% and 60%, respectively. At the median follow-up, FFLP for this cohort was 80.4%. FFLP for patients with hepatocellular carcinomas, colorectal metastasis, and all other lesions were 100%, 75%, and 83%, respectively. Conclusions This study describes the first clinical outcomes of MR-guided liver SBRT. Treatment was well tolerated by patients with excellent local control. This study lays the foundation for future dose escalation and adaptive treatment for liver-based primary malignancies and/or metastatic disease.

Purpose/Objective(s) COVID-19 has dramatically increased telehealth utilization for cancer care delivery. We hypothesized that patient satisfaction scores following virtual visits may improve over time as patients and physicians become more accustomed to a virtual platform. To evaluate this, we compared virtual visit patient satisfaction scores between early and late pandemic visits at a comprehensive cancer center. Materials/Methods Anonymized patient surveys from all virtual visit (VV) and in-person visits (IP) collected between April 2020 through January 2021 were included. Surveys consisted of 12 questions assessing the following aspects of the patient experience: connection quality, patient-physician communication, and overall provider quality. Open-ended questions (2/12) were excluded. Qualitative responses were given on a 1-3 Likert-type scale ranging from no, yes (somewhat), and yes (definitely). Surveys were grouped into early-pandemic (April 2020 - July 2020) and late-pandemic (August 2020 - January 2021). Responses were binned into satisfied (yes, [definitely] responses) and not satisfied (no and yes [somewhat] responses). Patient characteristics and survey responses for early and late pandemic were compared using a chi-square or independent t-test with significance set at P < 0.05. Results In total, 1,688 VV (45% early and 55% late pandemic) and 5,279 IP (39% early and 61% late pandemic) surveys were assessed. VV surveys were from the following specialties: 69% medical oncology, 13% surgical oncology, 12% radiation oncology, and 6% gynecologic oncology. The age distribution of VV patients was ≤49 (16%), 50-64 (28%), and ≥65 (56%) years compared to ≤49 (16%), 50-64 (32%), and ≥65 (52%) for IP patients. Survey response rates were 41% and 42% for VV and IP patients, respectively. Compared to early pandemic VV patients, late pandemic VV patients were more satisfied with regard to quality of explanation (91% vs 80%, P < .001), provider preparedness (89% vs 81%, P < 0.001), patient-provider trust (93% vs 87%, P < 0.001), provider listening (94% vs 86%, P < 0.001), follow-up instructions (85% vs 76%, P < 0.001), connection ease (83% vs 71%, P < 0.001), connection quality (85% vs 72%, P < 0.001), and appointment timing (84% vs 66%, P < 0.001). There was no significant difference between early and late pandemic for overall provider rating (mean [SD], 1-10 scale: 9.52 [1.45] vs. 9.58 [1.29], P = 0.36) or whether the patient would recommend the provider (94.6% vs. 92.3%, P = 0.10). In contrast, no significant differences were observed in patient survey scores between early and late pandemic for IP visits. Conclusion Patients who had virtual visits were significantly more satisfied on multiple aspects of their encounter later in the pandemic compared with earlier while no significant differences were observed for in-person visits. Understanding the underlying reasons will be important for optimizing the virtual patient experience, which is likely to remain a common way of “seeing” patients.

PURPOSE/OBJECTIVE(S) National Comprehensive Cancer Network guidelines recommend adjuvant systemic therapy with or without external beam radiation and/or intravaginal brachytherapy for high-risk endometrial cancer histologies. Being able to estimate the risk of pelvic/para-aortic lymph node (LN) involvement could assist in making clinical decisions regarding whether to treat with external beam versus brachytherapy alone. The National Cancer Data Base was queried to develop predictive nomograms based on primary uterine factors to estimate the risk of pathologic LN involvement. MATERIALS/METHODS Patients diagnosed with pathologic T1-T2 clear cell, uterine papillary serous (UPS), carcinosarcoma, or mixed endometrial cancer between 2004-2016 undergoing primary surgery with at least 10 LNs sampled in the National Cancer Data Base were identified. Logistic regression was performed to identify primary pathologic tumor predictors of LN positivity. Pathologic variables assessed included primary tumor histology, pathologic tumor stage, tumor size, and presence/absence of lymphovascular invasion (LVI). Nomograms were created to predict overall, pelvic only, and paraaortic and/or pelvic LN involvement. RESULTS Among 7,918 patients included, 1,407 (18%) were node positive. On multivariable analysis, relative to carcinosarcoma, both clear cell (odds ratio [OR] 1.77, 95% confidence interval [CI] 1.34-2.32, P < 0.001) and UPS (OR 1.76, 95% CI 1.46-2.13, P < 0.001) histology were significantly associated with a higher risk of LN positivity while mixed histology was not (OR 1.14, 95% CI 0.95-1.37, P = 0.16). Furthermore, increasing pathologic tumor stage (pT2 versus pT1a, OR 3.62, 95% CI 3.04-4.28, P < 0.001), increase in tumor size per centimeter (OR 1.09, 95% CI 1.06-1.11, P < 0.001), and presence of LVI (OR 5.23, 95% CI 4.58-6.02, P < 0.001) were predictive of overall LN positivity. Nomograms demonstrated that the impact of primary tumor pathologic variables was comparable for predicting any LN involvement, pelvic only, and paraaortic with or without pelvic LN involvement. CONCLUSION Among endometrial cancer patients with high-risk histologies, predictors of LN positivity are similar to those with endometrial adenocarcinoma. Patients with carcinosarcoma are the least likely to be diagnosed with node positive disease relative to other high-risk histologies. Predictive nomograms can help to individualize the risk of pelvic and paraaortic LN involvement and may assist in adjuvant treatment decisions. AUTHOR DISCLOSURE E. Anderson: None. M. Luu: None. D.J. Lu: None. E.M. Chung: None. M. Kamrava: American Board of Radiology, Brachytherapy Journal, American Brachytherapy Society Board of Directors. Co-Editor; Journal of Contemporary Brachytherapy.

Purpose To identify if baseline patient or magnetic resonance imaging (MRI) features can predict which women are at risk for inadequate tumor coverage with only intracavitary tandem and ovoid (T + O) brachytherapy and to correlate tumor coverage with clinical outcomes. Methods and Materials We performed a retrospective study of 50 women with cervical cancer treated with chemoradiation at a single institution between January 2014 and December 2015. All patients had a 3T-MRI performed at baseline (MRI1) and at the completion of external beam radiation therapy (MRI2). Gross tumor volume initial (GTV-Tinit) was measured on MRI1 and high-risk clinical tissue volume (CTVHR) on MRI2. CTVHR extending beyond point A was classified as too large for adequate coverage with T + O and requiring interstitial needles. Multivariate analysis was performed to determine predictive factors of inadequate coverage. Kaplan–Meier and Cox Regression were performed to correlate inadequate coverage with outcomes. Results Mean patient age was 49.2 ± 13.2 years, and 84% had Federation of Gynecology and Obstetrics IIB/IIIB disease. Forty-two percent of women were estimated to have inadequate tumor coverage with T + O brachytherapy. The GTV-Tinit volume and dimensions (superior-inferior, left-right, anterior-posterior) on MRI1 were all important predictive factors of inadequate coverage on multivariate analysis. Receiver operating characteristics curves identified optimal thresholds of superior-inferior ≥ 4.5 cm (area under the curve [AUC] = 0.718), left-right ≥ 4.5 cm (AUC = 0.745), anterior-posterior ≥ 5.0 cm (AUC = 0.767), and GTV-Tinit ≥ 85 cm3 (AUC = 0.842). Patients with inadequate coverage had worse clinical outcomes. Conclusions Baseline MRI tumor size may predict inadequate CTVHR coverage at the time of brachytherapy (i.e., the need for interstitial needles). This may help identify a subset of women requiring early referral to adequately resourced centers to improve clinical outcomes.

Purpose Given the limited data using an interstitial approach with 3D-based planning for definitive cervical cancer utilizing the GEC-ESTRO defined high-risk clinical target volume (HR-CTV), we reviewed our institutional experience of cervical cancer patients with HR-CTVs ≥ 30 cc to determine whether our clinical and toxicity outcomes are acceptable. Methods A retrospective review of 37 cervical cancer patients with high-risk clinical target volumes (HR-CTVs) ≥30 cc treated with interstitial image-guided brachytherapy (IS IGBT) was performed. All patients received external beam radiotherapy to a median dose of 45 Gy, followed by IS IGBT delivered in a single implant to a median dose of 6 Gy × 5 fractions. Median HR-CTV was 59 cc. A median HR-CTV D90 of 87.44 Gy was achieved. Kaplan–Meier method was used to evaluate local control (LC), distant control, and overall survival (OS), with stratification by overall treatment time (OTT) ≤ 7 or >7 weeks. Results Median followup was 17 months. The estimated 2-year LC, distant control, and OS were 77.6% (confidence interval [CI]: 63.8–94.5%), 56.8% (CI: 41.3–78.1%), and 54.4% (CI: 39.4–75%), respectively. The 2-year LC for OTT ≤7 weeks and >7 weeks were 100% and 58.3%, respectively (p = 0.026). The 2-year OS for OTT ≤7 weeks and >7 weeks were 77.8% and 38%, respectively (p = 0.021). Discussions IS IGBT can achieve a high D90 to the HR-CTV even in the setting of large-volume disease and results in a favorable LC and toxicity profile. OTT > 7 weeks is associated with significant decrease in LC and OS. Conclusions Efforts should be made to complete whole treatment within 7 weeks as this is associated with improved clinical outcomes.

Purpose: National studies suggest over fifty percent of physicians have feelings of burnout (Shanafelt et. al. Mayo Clin Proc 2015). This can result in emotional exhaustion, depersonalization, and reduced personal accomplishment. Left unmanaged this can lead to depression, addiction, and suicidal ideation. Burnout rates are reported for radiation oncology residents, program directors, and academic chairs but not amongst radiation oncologists who practice brachytherapy. The purpose of this study was to determine the rates of burnout amongst physician members of the American Brachytherapy Society (ABS). Materials and Methods: An anonymous online cross-sectional survey was performed of ABS physician members from December 2020 to February 2021. The survey was initially emailed from the ABS to members, followed by two participation reminders. Burnout was assessed by the Maslach Burnout Inventory-Human Service Survey (MBI-HSS), a validated 22-question survey. Thirteen additional demographics questions were included. High emotional exhaustion (EE) was defined a score of at least 27, high depersonalization was defined as a score of at least 10, and low personal accomplishment (PA) was defined by a score of no more than 33 (Rotenstein et. al. JAMA 2018). This study was approved by the Institutional Review Board. Results: Overall, 51 out of 400 members responded to the survey (13% response rate). Respondents were predominantly male (69%), married (78%), had 1-5 full time faculty or partners (59%), worked 51-60 hours per week (61%), deliver 6-10 brachytherapy treatments per week (43%), and have a brachytherapy suite in their department (63%). Six percent of respondents met the strict MBI-HSS criteria for high burnout (as defined by high EE, high DP, and low PA). Fifty-seven percent of respondents reported at least one manifestation of professional burnout (either high EE or DP). Based on individual MBI-HSS subscale scores, 47% of respondents demonstrated high EE, 37% high DP, and 16% low PA. Compared to prior surveys of radiation oncology academic chairs, residency program directors, and residents, survey respondents consistently had higher mean scores for EE and higher scores for DP, but higher scores for PA (Table 1). The most common identified stressors were electronic medical records (EMR) and excessive workload. Forty-seven percent of respondents also reported that COVID-19 increased their feelings of burnout. Respondents from academic facilities were more likely to have increased feelings of burnout due to COVID-19 (odds ratio 6.8, 95% CI 1.8-25.7). Conclusions: Nearly 60% of ABS physician members who responded to this survey reported symptoms of professional burnout with 6% meeting strict criteria for high burnout. This is higher than that reported for radiation oncology residents, program directors, or academic chairs. Managing stressors related to the EMR and workload are potential areas for improvement.

PURPOSE/OBJECTIVE(S) The American Academy of Pediatrics (AAP) endorses 12-weeks of paid parental leave based on studies showing health benefits to parents and children. Parental leave policies can impact the distribution of child-rearing duties, which may influence gender equity and retention of women in medicine. However, there is a paucity of data describing paid parental leave for faculty/staff physicians. We sought to evaluate paid parental leave policies for physicians at top U.S. hospitals and cancer centers. MATERIALS/METHODS Parental leave policies for the 2020-2021 U.S. News Top 20 Best Hospitals and Best Hospitals for Cancer were reviewed from publicly accessible websites, yielding 27 unique institutions. Human resources offices were contacted to verify policies. Duration of paid child-bearing and parental leave, salary support, and related provisions were obtained. Parental leave included leave available post-childbirth/disability for birthing mothers and for non-birthing mothers, partners, and adoptive parents. Paid leave was defined as receiving ≥50% of base salary and excluded regular accrued paid time off (e.g., vacation). If unpaid parental leave was available (< 50% base salary), paid parental leave duration was considered to be zero. RESULTS Of 27 institutions, six (22%) offer longer leave and/or greater pay based on the extent of caregiving responsibility (e.g., primary vs. secondary; n = 2) or employment position (e.g., academic faculty vs. non-faculty staff physician; n = 4). The mean duration of paid leave for birthing mothers (childbirth plus parental leave) is 7.8 weeks (range, 0-14 weeks) and for parental leave is 3.6 weeks (range, 0-12 weeks), using benefits from primary caregiver and academic faculty status where institutional benefits differ. Conversely, using benefits from secondary caregiver or non-faculty status where benefits differ, the mean paid leave for birthing mothers is 6.8 weeks (range, 0-12 weeks) and for parental leave is 2.3 weeks (range, 0-8 weeks). While the majority of hospitals (n = 23, 85%) offer short-term disability for childbirth, pay varies markedly (range, 0%-100%). Four institutions (15%) do not provide paid leave for childbirth and more than half (n = 15, 56%) do not provide paid parental leave beyond childbirth (based on secondary caregiver or non-faculty status where benefits differ). CONCLUSION Despite AAP endorsement of 12-weeks paid parental leave given improved outcomes for parents and children, the mean duration of paid maternity and parental leave at 27 leading U.S. hospitals and cancer centers is only 7.8 weeks and 3.6 weeks, respectively, at maximal benefits estimates. Nearly one-fourth of institutions offer different leave benefits based on faculty status and/or extent of caregiving responsibility. Future longitudinal studies are needed to assess the effect of paid parental leave on career satisfaction, work-life integration, and gender equity.

PURPOSE/OBJECTIVE(S) To evaluate the clinical and patient-reported outcomes and toxicities in prostate cancer patients undergoing HDR brachytherapy after TURP. MATERIALS/METHODS Data was prospectively collected for patients undergoing HDR brachytherapy from October 1991 to March 2016. Patients were classified according to NCCN risk criteria. Implants were performed under ultrasound-guidance with CT based planning. Goal dosimetric constraints included V100 Prostate > 95%, D1cc Urethra < 105%, D1cc Bladder < 75%, and D1cc Rectum < 75%. Multivariate cox analysis (MVA) was performed and adjusted for age, T stage, Gleason score, initial PSA, and androgen deprivation therapy (ADT) use. Sexual health inventory for men (SHIM) score, International Prostate Symptom Score (IPSS), and CTCAE v5.0 graded toxicity were recorded. RESULTS 2266 patients underwent HDR brachytherapy. 228 underwent a prior TURP. The median follow-up was 61.1 months (range 3 - 257.4 mos). The median time from TURP to HDR was 52.5 months (range 0.17 - 392 mos). A total of 641, 431, 617, and 577 patients were low-, favorable intermediate-, unfavorable intermediate-, and high-risk, respectively, of which 41, 49, 53, and 85 patients with TURP were low-, favorable intermediate-, unfavorable intermediate-, and high-risk, respectively. Patients with a prior history of TURP were more advanced in age and had a higher incidence of high-risk disease (P < 0.001). Of the patients with history of prior TURP, 49 (22%) and 54 (24%) patients experienced Gr 1 and 2 GU toxicity. 8 patients (3.5%) experienced grade 3 GU toxicity with a median time to occurrence of 16 mo (0.2 - 57.7 mo), and 3 of the Grade 3 toxicities resolved. No grade ≥4 GU toxicity and significant differences in toxicity were observed between the cohorts (P = 0.108). Patient-reported SHIM scores were found to not be statistically significant between prior TURP and non-TURP patients, with average decreases in SHIM no greater than 5 points at all time points in the TURP cohort. No significant differences were observed in biochemical free survival, distant metastases free survival, and prostate cancer specific survival at 4 and 8 years between patients who did and did not receive a prior TURP (8-yr BCFS 84.7% (95% CI: 78.2%-91.8%) vs. 89.1% (95% CI: 87.3-91.0%), respectively; P = 0.16). The TURP cohort was found to have lower overall survival (8-yr OS 72.0% (95% CI 64.8%-79.9%) vs. 81.9% (95% CI: 80.0% - 84.1%) respectively; P = 0.041), and may be attributed to the older age of the TURP cohort (P < 0.001). CONCLUSION HDR brachytherapy is a safe and effective treatment modality with low toxicity for prostate cancer patients after a prior TURP.

Purpose/Objective(s) Preoperative radiation therapy (RT) is an integral component of local control in soft tissue sarcoma (STS), but the conventional 5-week treatment course is burdensome for patients (pts). We conducted a single-institution phase 2 study of 5-day dose-equivalent preoperative RT for high-risk primary STS, which demonstrated acceptable rates of wound complications and 2-year toxicity. Here, we present results with longer follow-up, including additional pts from an expansion cohort. Materials/Methods The initial cohort accrued between April 2016 and May 2018 and included 52 pts with histologically confirmed extremity or trunk STS planning to undergo preoperative RT followed by surgery. The primary endpoint of the initial cohort was the rate of grade ≥2 radiation morbidity (fibrosis, lymphedema, or joint stiffness) at 2-years. An expansion cohort opened in October 2018 to compare wound complication rates between preoperative RT alone versus chemoRT and has enrolled an additional 47 pts. Patients received 30 Gy (RT alone) or 25 Gy (chemoRT) over 5 daily fractions to the primary tumor with standard margins. Here we report on pts with primary localized STS who completed preoperative RT and surgery in the initial and expansion cohorts (N = 79; chemoRT excluded). We assessed disease outcomes (local control, distant metastasis, and survival rates) and toxicity (grade ≥2 fibrosis, lymphedema, or joint stiffness) after minimum 2-year follow-up (N = 52). Fibrosis and joint stiffness were graded using RTOG/EORTC criteria, and lymphedema by Stern's scale. We also updated the major wound complication rate (defined per established criteria) after minimum 1-year follow up (N = 60). Results Of the 52 pts with minimum 2-year follow-up, predominant histologic subtypes included undifferentiated pleomorphic sarcoma, spindle cell sarcoma or sarcoma NOS (N = 24), myxofibrosarcoma (N = 8), and myxoid liposarcoma (N = 12). Median tumor size was 6.9 cm, and 15 pts had tumors ≥10 cm. At a median follow-up of 3 years, the local recurrence, distant metastasis and all-cause mortality rates were 6.5% (3 of 46 evaluable pts), 20.8% (10 of 48 evaluable pts), and 21.2% (11 of 52). Two of 3 pts (66%) with a local recurrence had undergone R1 resections, compared to 9 of 46 (19.5%) overall. The rate of overall grade ≥2 radiation morbidity in this same group was 13.0% (fibrosis: 5 pts, joint stiffness: 5 pts, lymphedema: 2 pts). Major wound complications were observed in 16 out of 60 (26.7%) evaluable pts. Conclusion Longer follow-up of a phase 2 study of 5-day pre-operative RT for pts with extremity/trunk STS demonstrates excellent local control. Rates of radiation fibrosis, joint stiffness and lymphedema, as well as wound complications, remain acceptable. We have also developed a web-based, interactive user interface for data visualization, which can help providers identify and understand relationships between baseline characteristics and clinical outcomes in our study.

PURPOSE/OBJECTIVE(S) Nodal staging systems vary substantially across solid tumors, which implies significant heterogeneity in the behavior of nodal variables across cancers. We hypothesized, in contradiction to this, that quantitative metastatic lymph node (LN) burden is a universal and dominant predictor of mortality across solid cancers, and therefore is capable of both simplifying and improving nodal staging for many cancers. MATERIALS/METHODS Retrospective cohort analysis of 1,304,498 patients in the National Cancer Database with solid cancers undergoing surgery between 2004-2015 across the 16 most common cancer sites in the United States (bladder, breast, cervix, colorectal, endometrium, esophagus, gastric, head and neck, hepatobiliary, lung, melanoma, ovary, pancreas, prostate, renal, thyroid). Restricted cubic spline modeling was used to assess the independent association of LN number and survival across a continuous nonlinear spectrum. Recursive partitioning analysis (RPA) was used to develop 16 nodal classification systems based on quantitative nodal burden. The reproducibility of these findings was assessed in 1,969,727 patients from SEER-18. RESULTS Consistently across all disease sites and without exception, mortality risk increased continuously and steeply with each +LN to a change point of ≤5 LN, and continued to increase more modestly without plateau beyond this (P < 0.001 for all hazard ratios [HRs] per LN of the initial and secondary spline segments). Disease sites with the highest HR per LN of the initial spline segment were melanoma (1.92/LN), bladder (1.66/LN) and renal (1.57/LN). Conversely, sites with the lowest HR per LN of the initial spline segment were thyroid (1.13/LN), ovary (1.19/LN) and endometrium (1.21/LN). RPA-derived nodal classification systems for all 16 disease sites universally produced multiple prognostic groups (between 3-8 depending on site) with non-overlapping survival curves that captured a wide spectrum of mortality risk (all P < 0.001). These RPA-derived systems demonstrated improved concordance with mortality compared to current AJCC nodal staging systems in disease sites without pathologic nodal classification based on number of positive LNs including bladder, cervix, endometrium, lung, ovary, prostate, and renal. The RPA-derived systems were also validated in an independent database, producing groups with distinct all-cause mortality and cause-specific mortality (all P < 0.001). Defining high nodal burden as the RPA-derived group with the highest number of +LNs, this factor conveyed markedly higher mortality (HR range: 1.8-4.6) than any other nodal covariate, including extranodal extension, size, and location (HR range: 0.9-1.5) in multivariable analysis across all organ sites. CONCLUSION Quantitative metastatic LN burden is a fundamental driver of mortality across solid cancers. Given its reproducibility and objectiveness, +LN number should serve as a foundation for pathologic nodal staging across all solid tumors.

To develop a consensus report for the quality practice of accelerated partial breast irradiation (APBI) using interstitial multicatheter brachytherapy (IMB).The American Brachytherapy Society Board appointed an expert panel with clinical and research experience with breast brachytherapy to provide guidance for the current practice of IMB. This report is based on a comprehensive literature review with emphasis on randomized data and expertise of the panel.Randomized trials have demonstrated equivalent efficacy of APBI using IMB compared with whole breast irradiation for select patients with early-stage breast cancer. Several techniques for placement of interstitial catheters are described, and importance of three-dimensional planning with appropriate optimization is reviewed. Optimal target definition is outlined. Commonly used dosing schemas include 50 Gy delivered in pulses of 0.6-0.8 Gy/h using pulsed-dose-rate technique and 34 Gy in 10 fractions, 32 Gy in eight fractions, or 30 Gy in seven fractions using high-dose-rate technique. Potential toxicities and strategies for toxicity avoidance are described in detail. Dosimetric constraints include limiting whole breast volume that receives ≥50% of prescription dose to60%, skin dose to ≤100% of prescription dose (≤60-70% preferred), chest wall dose to ≤125% of prescription dose, Dose Homogeneity Index to0.75 (0.85 preferred), VIMB is an effective technique to deliver APBI for appropriately selected women with early-stage breast cancer. This consensus report has been created to assist clinicians in the appropriate practice of APBI using IMB.

Purpose Patients with prostate cancer (PCa) containing Gleason pattern (GP) 5 disease experience a greater and earlier incidence of prostate cancer-specific mortality (PCSM) than general PCa patients. This affords the statistical power to compare PCSM outcomes among different treatment modalities even when restricting the analysis to patients treated in the modern era. The purpose of the present study was to compare the survival outcomes among patients with GP 5 PCa on needle core biopsy or transurethral resection of the prostate who underwent extremely dose-escalated radiation therapy (RT; exemplified by external beam RT with a brachytherapy boost [EBRT + BT]) versus radical prostatectomy (RP) in the modern era. Methods and Materials A total of 7669 men with a diagnosis of GP 5 PCa from 2004 to 2013 who had undergone EBRT + BT or RP were identified using the Surveillance, Epidemiology, and End Results database. After propensity score matching to balance the patient characteristics, PCSM was compared between modalities using a multivariate Fine and Gray competing risk model that accounted for other-cause mortality, with adjustment for age, race, GP, and clinical T stage. Results Patients treated with RP were younger and had a lower burden of GP 5, lower T stage, and lower other-cause mortality than patients who underwent EBRT + BT. After propensity score matching, no difference was found in PCSM between the RP and EBRT + BT groups (adjusted hazard ratio 1.018; P =.910). The cumulative 5-year PCSM incidence rates were 5.6% and 6.1% for patients undergoing RP and EBRT + BT, respectively. Patients with primary GP 5 experienced significantly greater PCSM than those with secondary GP 5, regardless of the treatment modality. Conclusions For patients with GP 5 PCa found on needle core biopsy or transurethral resection of the prostate, RP and EBRT + BT offer equivalent PCSM in a competing risk model after propensity score matching to balance the differences in patient characteristics.

BackgroundThe long natural history of prostate cancer (CaP) limits comparisons of efficacy between radical prostatectomy (RP) and external beam radiotherapy (EBRT), since patients treated years ago received treatments considered suboptimal by modern standards (particularly with regards to androgen deprivation therapy [ADT] and radiotherapy dose-escalation]. Gleason score (GS) 9-10 CaP is particularly aggressive, and clinically-relevant endpoints occur early, facilitating meaningful comparisons.ObjectiveTo compare outcomes of patients with GS 9-10 CaP following EBRT, extremely-dose escalated radiotherapy (as exemplified by EBRT+brachytherapy [EBRT+BT]), and RP.Design, setting, participantsRetrospective analysis of 487 patients with biopsy GS 9-10 CaP treated between 2000 and 2013 (230 with EBRT, 87 with EBRT+BT, and 170 with RP). Most radiotherapy patients received ADT and dose-escalated radiotherapy.Outcome measurements and statistical analysisKaplan-Meier analysis and multivariate Cox regression estimated and compared 5-yr and 10-yr rates of distant metastasis-free survival, cancer-specific survival (CSS), and overall survival (OS).Results and limitationsThe median follow-up was 4.6 yr. Local salvage and systemic salvage were performed more frequently in RP patients (49.0% and 30.1%) when compared with either EBRT patients (0.9% and 19.7%) or EBRT+BT patients (1.2% and 16.1%, p

Background and purpose Second malignancies (SM) after external beam radiotherapy (EBRT) or brachytherapy (BT) for prostate cancer (PCa) are rare but serious sequelae. Materials and methods The Surveillance, Epidemiology, and End Results (SEER) database was used to identify men diagnosed with cT1-2N0M0 PCa between 1999 and 2005, who underwent EBRT, BT or radical prostatectomy (RP). Patients with time interval to second malignancy or follow-up shorter than five and two years were excluded for solid and hematopoietic SM analyses respectively. Risks for solid and hematopoietic SM were evaluated via the multivariate Fine and Gray proportional hazards model. Results EBRT and BT resulted in similar increases in solid and hematopoietic SM compared to RP. In subgroup analysis stratified by treatment modality, only the EBRT cohort demonstrated significantly decreased solid and hematopoietic SM in years 2002–2005 compared to years 1999–2001, with adjusted-hazard ratios of 0.752 ( p =0.001) and 0.815 ( p =0.018) respectively. Conclusions EBRT and BT resulted in statistically equivalent increase in both solid and hematopoietic SM compared to RP. EBRT in more recent years resulted in significantly decreased solid and hematopoietic SM, coinciding with increased utilization of IMRT.

Purpose Outcomes using high-dose-rate (HDR) brachytherapy monotherapy (without androgen deprivation therapy or external beam radiation therapy) for National Comprehensive Cancer Network–defined intermediate-risk (IR) patients are limited. We report our long-term data using HDR monotherapy for this patient population. Methods and Materials One-hundred ninety IR prostate cancer patients were treated 1996–2013 with HDR monotherapy. Biochemical prostate-specific antigen (PSA) failure was per the Phoenix definition. Acute and late genitourinary and gastrointestinal toxicities were graded according to Common Toxicity Criteria of Adverse Events, version 4. Kaplan–Meier (KM) biochemical progression-free survival (BPFS), cause-specific survival, and overall survival rates were calculated. Univariate analyses were performed to determine relationships with BPFS. The median patient age was 66 years (43–90), and the median initial PSA was 7.4 ng/mL. The Gleason score was ≤6 in 26%, 3 + 4 in 62%, and 4 + 3 in 12%. The median treatment BED 1.5 was 254 Gy; 83% of patients were treated with a dose of 7.25 Gy × six fractions delivered in two separate implants. Results With a median follow-up of 6.2 years, KM BPFS at 5/8 years was 97%/90%, cause-specific survival at 8 years was 100%, and overall survival at 5/8 years was 93%/88%. Late genitourinary toxicities were 36.3% Grade 1, 18.9% Grade 2, and 3.7% Grade 3. Late gastrointestinal toxicities were 6.3% Grade 1, 1.1% Grade 2, and no Grade ≥3. Of the patients with no sexual dysfunction before treatment, 68% maintained potency. Age, initial PSA, T stage, Gleason score, prostate volume, and percent positive cores did not correlate with BPFS. Stratifying by favorable vs. unfavorable IR groups did not affect BPFS. Conclusions HDR brachytherapy monotherapy represents a safe and highly effective treatment for IR prostate cancer patients with long-term follow-up.

Purpose Cost estimates through traditional hospital accounting systems are often arbitrary and ambiguous. We used time-driven activity-based costing (TDABC) to determine the true cost of low-dose-rate (LDR) and high-dose-rate (HDR) brachytherapy for prostate cancer and demonstrate opportunities for cost containment at an academic referral center. Methods and Materials We implemented TDABC for patients treated with I-125, preplanned LDR and computed tomography based HDR brachytherapy with two implants from initial consultation through 12-month followup. We constructed detailed process maps for provision of both HDR and LDR. Personnel, space, equipment, and material costs of each step were identified and used to derive capacity cost rates, defined as price per minute. Each capacity cost rate was then multiplied by the relevant process time and products were summed to determine total cost of care. Results The calculated cost to deliver HDR was greater than LDR by $2,668.86 ($9,538 vs. $6,869). The first and second HDR treatment day cost $3,999.67 and $3,955.67, whereas LDR was delivered on one treatment day and cost $3,887.55. The greatest overall cost driver for both LDR and HDR was personnel at 65.6% ($4,506.82) and 67.0% ($6,387.27) of the total cost. After personnel costs, disposable materials contributed the second most for LDR ($1,920.66, 28.0%) and for HDR ($2,295.94, 24.0%). Conclusions With TDABC, the true costs to deliver LDR and HDR from the health system perspective were derived. Analysis by physicians and hospital administrators regarding the cost of care afforded redesign opportunities including delivering HDR as one implant. Our work underscores the need to assess clinical outcomes to understand the true difference in value between these modalities.

To compare patterns of prostate-specific antigen (PSA) response following stereotactic body radiation therapy (SBRT), high-dose-rate (HDR) brachytherapy, and conventionally fractionated intensity modulated radiation therapy (IMRT) in patients with low- or intermediate-risk prostate cancer (CaP).Eligible study patients included 439 patients with low- or intermediate-risk prostate cancer who were treated with radiation therapy (RT) alone between 2003 and 2013, remained free of biochemical recurrence, and had at least 2 PSA values within the first year following RT. Of these, 130 were treated with SBRT, 220 with HDR brachytherapy, and 89 with IMRT. Multivariate regression analysis was used to compare PSA nadirs (nPSA), time to nPSA, and PSA bounce parameters among the 3 modalities. Indicator variable analysis was used to develop empirical models of PSA decay using the treatment modalities as indicator variables.Significantly more patients treated with SBRT or HDR brachytherapy achieved raw nPSAs of0.5 ng/mL compared with patients treated with IMRT (76.2% and 75.9% vs 44.9%, respectively; P.0001 for SBRT or HDR brachytherapy vs IMRT). On multivariate analysis, nPSA was significantly lower with SBRT and HDR compared with IMRT (P.0001). Time to nPSA and bounce parameters was not significantly different among IMRT, SBRT, and HDR. Overall, SBRT and HDR brachytherapy caused significantly larger PSA decay rates (P.001). When truncating follow-up at 1000 days, the corresponding decay rates were larger for all 3 modalities, with no significant differences between them.Stereotactic body radiation therapy and HDR brachytherapy produce lower nPSAs than IMRT. Within 1000 days of follow-up, the modalities produce similar rates of PSA decay; subsequently, decay continues (albeit at a slower pace) after SBRT and HDR brachytherapy but plateaus with IMRT. Because nPSA is a validated predictor of long-term outcome, these data not only suggest a distinct radiobiological effect with SBRT and HDR brachytherapy, but also predict for clinical outcomes that might equal or surpass those of IMRT.

Purpose High-dose-rate (HDR) brachytherapy was originally used with external beam radiation therapy (EBRT) to increase the dose to the prostate without injuring the bladder or rectum. Numerous studies have reported HDR brachytherapy is safe and effective. We adapted it for use without EBRT for cases not requiring lymph node treatment. Patients and Methods We entered the patient demographics, disease characteristics, and treatment parameters into a prospective registry and serially added follow-up data for 448 men with low-risk (n=288) and intermediate-risk (n=160) prostate cancer treated from 1996 to 2009. Their median age was 64 years (range 42-90). The median prostate-specific antigen (PSA) level was 6.0 ng/mL (range 0.2-18.2). The Gleason score was ≤6 in 76% and 7 in 24%. The median dose was 43.5 Gy in 6 fractions. The clinical and biochemical disease control and survival rates were calculated. Adverse events were graded according to the Common Toxicity Criteria of Adverse Events. Results The median follow-up period was 6.5 years (range 0.3-15.3). The actuarial 6- and 10-year PSA progression-free survival was 98.6% (95% confidence interval [CI] 96.9%-99.4%) and 97.8% (95% CI 95.5%-98.9%). Overall survival at 10 years was 76.7% (95% CI 69.9%-82.2%). The local control, distant metastasis-free survival, and cause-specific survival were 99.7% (95% CI 97.9%-99.9%), 98.9% (95% CI 96.3%-99.7%), and 99.1% (95% CI 95.8%-99.8%). T stage, initial PSA level, Gleason score, National Comprehensive Cancer Network risk group, patient age, and androgen deprivation therapy did not significantly correlate with disease control or survival. No late grade 3 to 4 rectal toxicities developed. Late grade 3 to 4 genitourinary toxicity occurred in 4.9% (grade 3 in 4.7%). Conclusions HDR monotherapy is a safe and highly effective treatment of low- and intermediate-risk prostate cancer.